Category Archives: prisons
While eyes are on Russia, Sessions dramatically reshapes the Justice Department
The Washington Post reports: For more than five hours, Attorney General Jeff Sessions sat in a hearing room on Capitol Hill this month, fending off inquiries on Washington's two favorite topics: President Trump and Russia.
But legislators spent little time asking Sessions about the dramatic and controversial changes in policy he has made since taking over the top law enforcement job in the United States nine months ago.
From his crackdown on illegal immigration to his reversal of Obama administration policies on criminal justice and policing, Sessions is methodically reshaping the Justice Department to reflect his nationalist ideology and hard-line views — moves drawing comparatively less public scrutiny than the ongoing investigations into whether the Trump campaign coordinated with the Kremlin.
Sessions has implemented a new charging and sentencing policy that calls for prosecutors to pursue the most serious charges possible, even if that might mean minority defendants face stiff, mandatory minimum penalties. He has defended the president's travel ban and tried to strip funding from cities with policies he considers too friendly toward undocumented immigrants.
Sessions has even adjusted the department's legal stances in cases involving voting rights and lesbian, gay, bisexual and transgender issues in a way that advocates warn might disenfranchise poor minorities and give certain religious people a license to discriminate.
Supporters and critics say the attorney general has been among the most effective of the Cabinet secretaries — implementing Trump's conservative policy agenda even as the president publicly and privately toys with firing him over his decision to recuse himself from the Russia case. [Continue reading…]
This entry was posted in Department of Justice, Donald Trump, law enforcement, News, prisons on November 26, 2017 by News Sources.
The disturbing lessons of Trump's shameful Arpaio pardon
Scott Lemieux writes: During his very loosely hinged extemporaneous remarks in Phoenix on Tuesday, President Trump strongly hinted that he would pardon the infamous former Maricopa County Sheriff Joe Arpaio. On Friday evening, with a frightening hurricane descending on Texas, Trump made it official. The decision to issue his first pardon to a public official who made his reputation, such as it is, through race-baiting and a contempt for both legal restraints and basic human decency tells us a lot about Trump — and none of it is good.
It is highly relevant that Trump and Arpaio first became allies while Trump was rising to prominence within the Republican Party by pushing the racist conspiracy theory that Barack Obama was not born in the United States. The Arizona sheriff actually launched a farcical investigation into Obama's birth certificate, wasting taxpayer money to build his cred with his resentful white supporters. That Arpaio and Trump would become mutual admirers was inevitable.
It should go without saying that Arpaio is a terrible candidate for a pardon. If you have any doubts, read this chilling 2009 profile of Arpaio by William Finnegan in The New Yorker. Arpaio's first claim to local fame was to make the conditions of imprisonment for inmates under his jurisdiction as inhumane as possible — housing thousands of people in tents next to cites like dumps and waste disposal plants in the brutal Arizona heat. He fed inmates for 30 cents a meal, two meals a day, and then made the Food Network one of three channels available to prisoners. He put many people who were being held for trial and had not been convicted of any crime to work on chain gangs. Under his watch, guards were so consistently cruel to inmates that the county had amassed more than $40 million in civil damages from lawsuits. And he also engaged in egregious racial profiling when detaining people suspected of being illegal immigrants.
Arpaio's focus on abusing prisoners and arbitrarily detaining people of Latin American descent also made his "tough on crime" reputation grossly misleading. The resources wasted on his cruel publicity stunts took money away from law enforcement, slowing response times and leading to (among other problems) hundreds of botched or perfunctory sex crimes investigations. He did, however, find the time to file frivolous charges against two journalists who were looking into his suspicious property dealings, leading to another huge legal settlement for Maricopa County's taxpayers to pay off. [Continue reading…]
This entry was posted in 2016 President Election, Analysis, Donald Trump, immigration, law, law enforcement, News, prisons, racism on August 26, 2017 by News Sources.
The incarceration industry was having a tough time. Then Trump got elected
James Surowiecki writes: Going into Election Day, few industries seemed in worse shape than America's private prisons. Prison populations, which had been rising for decades, were falling. In 2014, Corrections Corporation of America, the biggest private-prison company in the U.S., lost its contract to run Idaho's largest prison, after lawsuits relating to understaffing and violence that had earned the place the nickname Gladiator School. There were press exposés of shocking conditions in the industry and signs of a policy shift toward it. In April, Hillary Clinton said, "We should end private prisons." In August, the Justice Department said that private federal prisons were less safe and less secure than government-run ones. The same month, the department announced that it would phase out the use of private prisons at the federal level. Although most of the private-prison industry operates on the state level (immigrant-detention centers are its other big business), the news sent C.C.A.'s stock down by thirty-five per cent.
Donald Trump's victory changed all that: within days, C.C.A.'s stock had jumped forty-seven per cent. His faith in privatization is no secret, and prison companies aren't the only ones rubbing their hands. The stock price of for-profit schools has also rocketed. Still, the outlook for private prisons is particularly rosy, because many Trump policies work to their benefit. The Justice Department's plan to phase out private prisons will likely be scrapped, and a growing bipartisan movement for prison and sentencing reform is about to run up against a President who campaigned as a defender of "law and order." Above all, Trump's hard-line position on immigration seems certain to fill detention centers, one of the biggest money spinners for private-prison operators. [Continue reading…]
This entry was posted in Analysis, Donald Trump, prisons on November 28, 2016 by News Sources.
Private prison companies ready to cash in on throwing out immigrants
The Daily Beast reports: When the children were released from the privately run immigration detention facility in Karnes City, Texas, they were immediately taken to the emergency room with pneumonia.
Over the past few months, several children who fled from violence in South and Central America with their mothers have been hospitalized after leaving the facility run by GEO Group, a private prison company that saw its stocks jump following Election Day. The children's health problems were the result of poor medical care inside what is essentially a prison for mothers and their children, according to Amy Fischer of the Refugee and Immigrant Center for Education and Legal Services.
With Donald Trump now president-elect, the Karnes City facility and a dozen more like it across the country are preparing to fill even more beds with immigrants and refugees. GEO Group and another private prison company, Corrections Corporation of America, are also preparing for more large, lucrative contracts with the federal government to run the detention centers.
Both companies saw their stock prices soar following Trump's historic and shocking win. [Continue reading…]
This entry was posted in Analysis, immigration, prisons, Trump administration on November 18, 2016 by News Sources.
Rebecca Gordon: Arresting our way to 'justice'
The figures boggle the mind. Approximately 11 million Americans cycle through our jails and prisons each year (including a vast "pre-trial population" of those arrested and not convicted and those who simply can't make bail). At any moment, according to the Prison Policy Initiative, there are more than 2.3 million people in our "1,719 state prisons, 102 federal prisons, 942 juvenile correctional facilities, 3,283 local jails, and 79 Indian Country jails as well as in military prisons, immigration detention facilities, civil commitment centers, and prisons in the U.S. territories." In some parts of the country, there are more people in jail than at college.
If you want a partial explanation for this, keep in mind that there are cities in this country that register more arrests for minor infractions each year than inhabitants. Take Ferguson, Missouri, now mainly known as the home of Michael Brown, the unarmed black teenager shot and killed in 2014 by a town policeman. The Harvard Law Review reported that, in 2013, Ferguson had a population of 22,000. That same year "its municipal court issued 32,975 arrest warrants for nonviolent offenses," or almost one-and-a-half arrests per inhabitant.
And then there are the conditions in which all those record–breaking numbers of people live in our jails and prisons. At any given time, 80,000 to 100,000 inmates in state and federal prisons are held in "restrictive housing" (aka solitary confinement). And those numbers don't even include county jails, deportation centers, and juvenile justice institutions. Rikers Island, New York City's infamous jail complex in its East River, has 990 solitary cells. And keep in mind that solitary confinement — being stuck in a six-by-nine or eight-by-10-foot cell for 23 or 24 hours a day — is widely recognized as a form of psychosis-inducing torture.
And that, of course, is just to begin to explore America's vast and ever-expanding prison universe. The fact is that it's hard to fathom even the basics of the American urge to lock people away in vast numbers, which is why today TomDispatch regular Rebecca Gordon focuses instead on what it might mean for justice in this country if we started to consider alternatives to prison. Tom Engelhardt
There oughta be a law…
Should prison really be the American way?
By Rebecca Gordon
You've heard of distracted driving? It causes quite a few auto accidents and it's illegal in a majority of states.
Well, this year, a brave New Jersey state senator, a Democrat, took on the pernicious problem of distracted walking. Faced with the fact that some people can't tear themselves away from their smartphones long enough to get across a street in safety, Pamela Lampitt of Camden, New Jersey, proposed a law making it a crime to cross a street while texting. Violators would face a fine, and repeat violators up to 15 days in jail. Similar measures, says the Washington Post, have been proposed (though not passed) in Arkansas, Nevada, and New York. This May, a bill on the subject made it out of committee in Hawaii.
That's right. In several states around the country, one response to people being struck by cars in intersections is to consider preemptively sending some of those prospective accident victims to jail. This would be funny, if it weren't emblematic of something larger. We are living in a country where the solution to just about any social problem is to create a law against it, and then punish those who break it.
This entry was posted in prisons, TomDispatch, United States on September 26, 2016 by TomDispatch.
The U.S. is the largest jailer of children in the world
Liz Ryan writes: The mass incarceration epidemic in the US has been getting much-deserved attention in recent years. What's less well known is that some of the worst atrocities in the prison system are being committed against children—the US is the largest jailer of children in the world. With the looming presidential election putting prison reform in the spotlight, now is the time to reverse decades of bad policies.
Putting children in prison has a devastating impact on their families and communities, as well as on young people themselves. There are many examples of these atrocities in action. The Lincoln Hills youth facility in Irma, Wisconsin, is one of the largest youth prisons in the US. In the past 18 months, the facility has been the subject of federal and state investigations stemming from allegations of physical and sexual abuse, as well as guards using intimidation tactics to discourage youth from reporting incidents of pepper spray use, strangulation, and suffocation. In one incident, a boy's toes were amputated after a staff member slammed a heavy door on his foot.
For the past several years, the Connecticut Juvenile Training School, Connecticut's largest youth prison, has been under multiple investigations by the Office of the Child Advocate for excessive use of isolation, overuse of restraints, inadequate suicide prevention, lack of appropriate staff support and training, inadequate and harmful crisis management, and scant available information on quality, public safety outcomes, and oversight. Last year, the Child Advocate's office released video of staff members conducting face-down restraints on young people at the training school—which are illegal in Connecticut schools and treatment centers. [Continue reading…]
This entry was posted in Analysis, human rights, prisons, United States on September 1, 2016 by News Sources.
The secret U.S. prisons you've never heard of before
This entry was posted in Analysis, human rights, prisons, United States, US government on August 31, 2016 by News Sources.
Hate preachers to be held in separate prison units in England and Wales to curb radicalisation
The Guardian reports: Influential hate preachers will be held in separate prison units after an official inquiry found inmates were acting as "self-styled emirs" behind bars.
A government-ordered review into radicalisation in jails has concluded that some charismatic prisoners exerted a "radicalising influence" over fellow Muslims. It also claimed that some have attempted to engineer segregation, encouraged aggressive conversions to Islam, and been involved in the intimidation of prison imams.
The claims have emerged in a review led by former prison governor Ian Acheson and commissioned last year by then justice secretary Michael Gove. Such concerns in Whitehall were disclosed by the Guardian in February.
Its conclusions will overturn 50 years of dispersing the most dangerous prisoners across the prisons system. Critics have previously warned that such a move could also provide a focal point for public protests and claims of a "British Guantanamo". [Continue reading…]
This entry was posted in ISIS, Islamic extremism, prisons, United Kingdom on August 22, 2016 by News Sources.
How safe is it to lock up Anjem Choudary in prison with Muslims he could radicalise?
Andrew Neilson writes: The conviction of the cleric Anjem Choudary for inviting support for the Islamic State (Isil) brings into sharp focus a longstanding concern about prisons and radicalisation. The spectre is that jailed Islamist extremists – or indeed any other kind of political extremist – find that there is no better recruiting ground for their cause than prisons themselves.
We know, for example, that a number of extremists behind recent terror attacks in France associated with Isil had spent time in the French prison system and had been radicalised there. Now a man described as the "most dangerous man in Britain", who counter-terrorism chiefs have spent the best part of two decades pursuing on charges of radicalisation, will most likely be sent to prison for many years. What might he achieve in the potentially fertile recruiting ground of British prisons?
As it happens, and possibly with the looming conviction of Choudary in mind, the former Secretary of State for Justice Michael Gove commissioned a review into Islamist extremists in prison. That review is yet to be published, and with the appointment of Elizabeth Truss to the Ministry of Justice its future is currently rather uncertain. We do know, however, that the review found that such extremism is a growing problem within prisons (although we do not know what data the review relied upon to reach this conclusion). The review also found the National Offender Management Service, which oversees the prison system, lacked a coherent strategy to deal with the problem. Some 69 recommendations were made for change. [Continue reading…]
This entry was posted in Analysis, Islamic extremism, prisons on August 17, 2016 by News Sources.
'Abu Ghraib'-style images of children in detention in Australia trigger public inquiry
The Guardian reports: Australia's prime minister has launched a public inquiry following the broadcast of footage of children in detention being abused, hooded and bound in a manner likened to Abu Ghraib and Guantánamo Bay.
Malcolm Turnbull announced a royal commission hours after the national broadcaster aired shocking footage showing children in detention at the Don Dale facility outside Darwin in the Northern Territory.
Footage aired on the ABC's Four Corners program on Monday showed one youth being stripped and physically held down by guards.
In another scene that the program compared with images from Guantánamo Bay or the Abu Ghraib jail in Baghdad, 17-year-old Dylan Voller was shown hooded and tied in a restraint chair for two hours. [Continue reading…]
This entry was posted in Australia, News, prisons, torture on July 26, 2016 by News Sources.
How to stop prisons from turning criminals into terrorists
Cullen Thomas writes: Each time I learn of another terrorist who spent time in prison, I'm taken back to my own prison time. In 1994, I was caught smuggling hashish into South Korea and spent three and a half years imprisoned there. Since then I've struggled to understand the nature of confinement and its effects on the individual.
It's a striking and clear pattern that many of the most notorious terrorists of the modern era spent time in prison. Salah Abdeslam, the suspect behind the Paris and Brussels terror attacks, was imprisoned in Belgium with Abdelhamid Abaaoud, who lead the Friday the 13th attacks in Paris last November.
Chérif Kouachi and Amedy Coulibaly, responsible for the Charlie Hebdo and kosher supermarket attacks in Paris earlier in 2015, were imprisoned in France's massive Fleury-Mérogis, Europe's largest prison.
Ayman al-Zawahiri, before he became right-hand man to Osama bin Laden, was radicalised in Egyptian prisons. As Lawrence Wright, author of The Looming Tower: Al-Qaeda and the Road to 9/11 (2006), put it, Zawahiri 'entered prison a surgeon. He came out of it a butcher.' [Continue reading…]
This entry was posted in Al Qaeda, Analysis, ISIS, prisons, terrorism on May 5, 2016 by News Sources.
Solitary confinement is 'no touch' torture, and it must be abolished
Chelsea E Manning writes: Shortly after arriving at a makeshift military jail, at Camp Arifjan, Kuwait, in May 2010, I was placed into the black hole of solitary confinement for the first time. Within two weeks, I was contemplating suicide.
After a month on suicide watch, I was transferred back to US, to a tiny 6 x 8ft (roughly 2 x 2.5 meter) cell in a place that will haunt me for the rest of my life: the US Marine Corps Brig in Quantico, Virginia. I was held there for roughly nine months as a "prevention of injury" prisoner, a designation the Marine Corps and the Navy used to place me in highly restrictive solitary conditions without a psychiatrist's approval.
For 17 hours a day, I sat directly in front of at least two Marine Corps guards seated behind a one-way mirror. I was not allowed to lay down. I was not allowed to lean my back against the cell wall. I was not allowed to exercise. Sometimes, to keep from going crazy, I would stand up, walk around, or dance, as "dancing" was not considered exercise by the Marine Corps.
To pass the time, I counted the hundreds of holes between the steel bars in a grid pattern at the front of my empty cell. My eyes traced the gaps between the bricks on the wall. I looked at the rough patterns and stains on the concrete floor – including one that looked like a caricature grey alien, with large black eyes and no mouth, that was popular in the 1990s. I could hear the "drip drop drip" of a leaky pipe somewhere down the hall. I listened to the faint buzz of the fluorescent lights.
For brief periods, every other day or so, I was escorted by a team of at least three guards to an empty basketball court-sized area. There, I was shackled and walked around in circles or figure-eights for 20 minutes. I was not allowed to stand still, otherwise they would take me back to my cell. [Continue reading…]
This entry was posted in Analysis, Defense Department, human rights, Obama administration, prisons, torture on May 3, 2016 by News Sources.
Little evidence to show that prisons have become 'universities of terror'
By Sarah Marsden, Lancaster University
From "shoebomber" Richard Reid, to Abdelhamid Abaaoud, the ringleader of the attacks in Paris, there seem to be increasing examples of people becoming "radicalised" in jails. So how concerned should we be about the role of prisons in producing violent extremists?
Contrary to those who argue that jails are at risk of becoming "universities of terror" there is actually relatively little systematic evidence of a link between prison and involvement in terrorism.
That is not to say that apparently "radical" groups have not developed in prisons, or that there haven't been efforts to recruit people to militant Islamism in UK jails. Jamaal Uddin, who was convicted for assault and enforcing a "Sharia-controlled zone" in east London, boasted of his ability to "radicalise" people in the face of apparently powerless authorities. In the worst cases, such as in Iraq where several American-run detention facilities became pivotal in the development of what was to become Islamic State, prisons have been intimately implicated in terrorism.
This entry was posted in Analysis, ISIS, prisons on November 23, 2015 by News Sources.
The Kingdom of Silence: Literature from Tadmor prison
Linah Alsaafin reports: "When death is a daily occurrence, lurking in torture, random beatings, eye-gouging, broken limbs and crushed fingers… [When] death stares you in the face and is only avoided by sheer chance…wouldn't you welcome the merciful release of a bullet?"
This was taken from a report smuggled out in 1999 to Amnesty International by a group of former Syrian prisoners who had spent years in the infamous Tadmor (Arabic for Palmyra) prison, where unimaginable acts of torture took place against both dissidents and criminals alike.
Tadmor prison fell to the Islamic State group as it captured the city of Palmyra from government forces earlier this week, but the significance of its seizure has been overshadowed by widespread fears that IS could raze the UNESCO World Heritage site just south of the modern town. In fact the capture of the prison could be a much more important development, according to analysts and former inmates of the jail.
The prison, which used to be a French military barracks, is located in the desert in eastern province of Homs and is around 200 kilometres away from the capital Damascus. As previously reported by Middle East Eye, the massacre of hundreds of prisoners in 1980 after a foiled assassination attempt on then president Hafez al-Assad exacerbated the prison's symbolic status of repression.
Human rights reports were not the only medium to document what took place in what has been described as one of the worst prisons in the world.
The vicious reality of Tadmor, where the blood of those massacred in 1980 was not cleaned up resulting in the mass spread of gangrene amongst the rest of the inmates, created literary works written by survivors and former inmates that narrated their daily lives in stark detail. Whips were given human names, friendships were struck between prisoners and rats and cockroaches, and torture sessions were opportunities to experiment with excruciating devices.
This entry was posted in Analysis, prisons, Syria, torture on May 24, 2015 by News Sources.
This man came from Rome to show Americans why the death penalty is wrong
Cosimo Bizzarri writes: Today, 105 countries around the world have abolished the death penalty by law and 43 more have approved public or de facto moratoria against it. Among them are Gabon and Mongolia, Cambodia and Russia, Albania and Kyrgyzstan. In Cuba, death row is currently empty.
Worldwide, only a few dozens countries still stick to the death penalty, opposing the 2007 UN resolution that called for a global moratorium on its use. Among them, the most prolific executioners are China, Iraq, Iran, Saudi Arabia and the United States, which has killed more than 1,400 people since 1976. Currently, the US holds more than 3,000 people in death row, including recently-sentenced Boston Marathon bomber Dzhokhar Tsarnaev.
"Some US citizens, especially in the South, grew up with the idea that retributive justice is the only justice," explains Italian journalist and human right activist Mario Marazziti to Quartz. "This opinion is sometimes based on a fundamentalist reading of the Old Testament."
Marazziti, 62, is the spokeperson for the Community of Sant'Egidio, a Rome-based Catholic movement for peacemaking and human rights, and a co-founder of the World Coalition Against the Death Penalty. In the 1990s, Marazziti collected 3 million signatures in 157 countries calling for a worldwide moratorium against the death penalty. [Continue reading…]
This entry was posted in Analysis, Ethics, prisons, United States on May 24, 2015 by News Sources.
The cruel and unusual execution of Clayton Lockett
Jeffrey E. Stern reports: On the morning of his execution, Clayton Lockett hid under the covers.
Before a team of correctional officers came to get him at 5:06 a.m., he fashioned a noose out of his sheets. He pulled the blade out of a safety razor and made half-inch-long cuts on his arms. He swallowed a handful of pills that he'd been hoarding. And on April 29, 2014, when the team of officers knocked on the door of his cell in the Oklahoma State Penitentiary in McAlester, Oklahoma, Clayton Lockett — a 38-year-old convicted murderer — pulled a blanket over his head and refused to get up.
The officers left and asked for permission to tase him. While they were gone, Lockett tried to jam the door. They came back, forced their way in, tased him, and dragged him out.
Eleven hours later, at about 5:20 p.m., after a medical examination, X‑rays, eight hours in a holding cell, and a shower, Lockett was brought by a five-member strap-down team into the death chamber. It was a small, clinical-looking room with white walls and a polished floor that reflected the lights overhead. A gurney stood in the center of the room; above it hung a microphone for Lockett's final words. [Continue reading…]
This entry was posted in Analysis, crime, Ethics, prisons, United States on May 15, 2015 by News Sources.
The use of force against the mentally ill incarcerated in America
Human Rights Watch: Jail and prison staff throughout the United States have used unnecessary, excessive, and even malicious force against prisoners with mental disabilities, Human Rights Watch charged in a report released today.
The 127-page report, "Callous and Cruel: Use of Force against Inmates with Mental Disabilities in US Jails and Prisons," details incidents in which correctional staff have deluged prisoners with painful chemical sprays, shocked them with powerful electric stun weapons, and strapped them for days in restraining chairs or beds. Staff have broken prisoners' jaws, noses, ribs; left them with lacerations requiring stitches, second-degree burns, deep bruises, and damaged internal organs. In some cases, the force used has led to their death.
"Jails and prisons can be dangerous, damaging, and even deadly places for men and women with mental health problems," said Jamie Fellner, US program senior adviser at Human Rights Watch and the author of the report. "Force is used against prisoners even when, because of their illness, they cannot understand or comply with staff orders."
This entry was posted in Analysis, News, prisons, United States on May 12, 2015 by News Sources.
Mass incarceration: The silence of the judges
Jed S. Rakoff writes: For too long, too many judges have been too quiet about an evil of which we are a part: the mass incarceration of people in the United States today. It is time that more of us spoke out.
The basic facts are not in dispute. More than 2.2 million people are currently incarcerated in US jails and prisons, a 500 percent increase over the past forty years. Although the United States accounts for about 5 percent of the world's population, it houses nearly 25 percent of the world's prison population. The per capita incarceration rate in the US is about one and a half times that of second-place Rwanda and third-place Russia, and more than six times the rate of neighboring Canada. Another 4.75 million Americans are subject to the state supervision imposed by probation or parole.
Most of the increase in imprisonment has been for nonviolent offenses, such as drug possession. And even though crime rates in the United States have declined consistently for twenty-four years, the number of incarcerated persons has continued to rise over most of that period, both because more people are being sent to prison for offenses that once were punished with other measures and because the sentences are longer. For example, even though the number of violent crimes has steadily decreased over the past two decades, the number of prisoners serving life sentences has steadily increased, so that one in nine persons in prison is now serving a life sentence.
And whom are we locking up? Mostly young men of color. Over 840,000, or nearly 40 percent, of the 2.2 million US prisoners are African-American males. Put another way, about one in nine African-American males between the ages of twenty and thirty-four is now in prison, and if current rates hold, one third of all black men will be imprisoned at some point in their lifetimes. Approximately 440,000, or 20 percent, of the 2.2 million US prisoners are Hispanic males. [Continue reading…]
This entry was posted in Analysis, crime, Department of Justice, inequality, law, prisons, racism on May 5, 2015 by News Sources.


Depression in Primary Care: Clinical Epidemiology & Clinical Decision Aalysis
January-June 2006 Volume 3(1)
Special Article
Haider Naqvi
A clinical decision analysis (CDA) is a mathematical tool designed to facilitate complex clinical decisions in which many variables should be considered simultaneously. CDA is a feasible tool for multifaceted problem of management of depression in primary health care. It provides a systematic frame work for organizing all data relevant to the decision on recognition and management of depression. Clinical epidemiological perspective is used for assessing the validity of screening instrument. A decision matrix based on reported probabilities is also constructed. Chance nodes and decisions pertinent to comorbidities, illness severity and treatment options for depression are also presented.
Key words: Clinical epidemiology, Clinical decision Analysis, Depressive disorder, primary care, Pakistan.
New millennium has witnessed an epidemiological transition with rise in burden of non-communicable diseases. According to 1993 World Bank Report Neuropsychiatric diseases (including self-inflicted injuries) contribute 8.1% to the Global Burden of Diseases (GBD). Subsequently this contribution to GBD has been reanalyzed and found to be 10.5%. This is projected to increase to 15% by the year 2020. The "behavior related problems" contribute an additional 34% to GBD1.
Prevalence of common mental disorders is estimated to be 30 % to 50% in primary care settings of Pakistan. Most patients with mental disorders initially consult their general physicians (GP)2. Although CMD have been diagnosed in third of primary care attendees in developing Asian countries, primary care staff is generally reported to recognize only 10 % of the cases. Studies have shown that a substantial proportion of mental disorders in primary care are inadequately managed by the GPs3. There are many facets to this complex problem. Some issues are related to the physicians while other to the patients. Lack of time, awareness and general stigma related to mental illness poses a major problem for GPs4.
Patients presenting in primary care are much different from psychiatric settings. Generally they have concurrent medical illness, which remains the major focus of management. Another common reason for this under recognition is somatisation, i.e., presentation of psychological distress as somatic symptoms, and poor awareness of this in health professionals5.
A clinical decision analysis (CDA) appears to be a feasible tool for this multifaceted problem. CDA is a mathematical tool designed to facilitate complex clinical decisions in which many variables should be considered simultaneously. It provides a systematic frame work for organizing all data relevant to the decision. It also assigns a numerical value to various courses of actions, simplifying comparison among them6.
This is particularly relevant in the context of Pakistan, a South East Asian developing country. With the dearth of mental health professionals, management of common mental disorders is increasingly integrated in to primary health care. Complex clinical decisions are either delegated to clinical nurses or lady health workers. With explicit decision analysis, there is greater likelihood of adequate management of common mental disorders (depression and anxiety) in primary health care. CDA will also serve to promote informed consent as patients input can be taken in to account in evaluating outcomes.
Clinical Decision Analysis and Management of Depressive Disorder in Primary Health Care:
Major depression is a disorder characterized by persistent and pervasive low mood, anhedonia, impaired concentration, disturbed sleep, appetite and morbid death wishes. The point prevalence of major depression from community based studies is estimated to be between 25-66 % for females and 10-44% for males7,8. The prevalence estimates for MDD in primary care settings of Pakistan is estimated to be approximately 30% to 50%2. These are many times higher when compared with western countries. Additional problem is dearth of trained mental health professionals and scarcity of allocated resource.
A clinical decision analysis and algorithm appears feasible in order to address the above needs and rectify potential problems in the management of depression in primary health care. A rough guide and skeleton of the decision analysis is presented in Figures 1 and 2. Probability estimates of certain outcomes and potential multidimensional utility is presented when and where objective literature on the subject was available.
Fig. 1: Clinical decision Analysis: Management of Depression in Primary care.
CLINICAL DECISION ANALYSIS
D1: Decision Node 1; multiple somatic symptoms of Unknown origin.
C1: Chance node 1; Chance of Functional depressive illness (Pr 0.64)
C2: Chance node 2; Chance of Depression secondary to Co morbid medical condition (Pr 0.36)
C3: Chance node 3; Chances of no Thyroid abnormality (Pr 0.95).
C4: Chance node 4; Chance of Sub clinical Thyroid abnormality (Pr 0.05).
D2: Decision Node 2: Decision on severity of illness. C5: Chance node 5; Chance of mild-to-moderate depression (Pr 0.86; Detection rate 18.4%).
C6: Chance node 6; Chance of severe depression (Pr .13; detection rate 73%)
D3: Decision on Psychotherapy based on the severity (mild-to-moderate) and patient's preference.
D4: Decision on Antidepressants Medication based on severity.
D5: Decision to treat the underlying medical illness.
Figure 2: Clinical decision Analysis: Management of Depression in Primary care
(Final model after pruning the figure 1)
C1: Chance node 1; Chance of Functional depressive illness (Pr 0.64).
C2: Chance node 2; Chance of Depression secondary to Co morbid medical condition (Pr 0.36).
D2: Decision Node 2: Decision on severity of illness.
C5: Chance node 5; Chance of mild-to-moderate depression (Pr 0.86; Detection rate 18.4%).
C6: Chance node 6; Chance of severe depression (Pr .13; detection rate 73%).
D3: Decision on Psychotherapy based on the severity and patient's preference.
Somatic symptoms and high index of suspicion for depression (Node – D-1):
In primary care setting the most common presentation of patients' with depression is with multiple somatic symptoms. This premise is based on the comparative studies carried out by Mumford et al looking specifically at the somatic manifestation of psychological symptoms in the context of Pakistan. The sample population was group of people in Lahore, Pakistan and Leeds, U.K9,10. The decision node D-1 pertains to maintaining high index of suspicion for depression when patients' present with multiple somatic symptoms of unexplained nature. There is no study from Pakistan looking specifically at the characteristics or out come of this atypical presentation in Primary care.
The chance node C-1 pertains to the probability of somatic symptoms, given that the patient has underlying depressive illness (Pr 0.64). The chance node C-2 pertains to having somatic symptoms given that patient has underlying medical co morbidity.
According to studies carried out in the west, significant depressive symptoms are seen in 36% of medically ill patients11. Those with dementia, diabetes, stroke, hypercortisolism, asthma and renal impairment have especially high rates of co- morbid depression. Conditions like fibromyalgia and chronic fatigue syndrome, exists at the interface of medicine and psychiatry and are associated with major depressive disorder12,13.
Depression is also associated with use of medications. 3% of patients on high dose steroids report significant symptoms of depression. Calcium channel blockers, beta-blockers and digoxin are known to cause depression. Caffeine use may be associated with increased side effects and failure of some symptoms to improve (for e.g. anxiety and insomnia). Co morbid alcohol use and withdrawal from alcohol and stimulants are associated with depression14-16. Co morbid depression will require a similar treatment strategy as functional depression, besides the concurrent medical management.
Among these patients work up for thyroid abnormality should be carried out in order to rule out psychological symptoms secondary to thyroid abnormality (Node C-3). Thyroid abnormality typically mimics symptoms of depression and should be exclusively ruled out in the context of primary care. There are no studies from Pakistan on prevalence of abnormal thyroid hormones in the setting of primary care. However in clinical population (PC) from western countries it is estimated to be around 5 % (Node C4). In psychiatric subset with chronic treatment resistant depression, the prevalence of subthreshold thyroid abnormality is estimated to be much higher (around 50%)12.
After ruling out secondary and co morbid depression it is pertinent to establish the diagnosis of depression. Use of screening test/instrument is particularly relevant in the context primary care, where constraints of time and resources demands rapid assessment. It should be considered that any screening test, however robust it may be has its limitations. Result of screening instrument should be checked against a gold standard, measure of assessment. A brief discussion on the definition, process and limitations of screening is particularly relevant here, followed by issues pertaining to screening for depression in primary care setting.
Clinical decision analysis and disease screening:
Screening has been defined as "presumptive identification of unrecognized disease or defect by the application of test, examination, or procedure which can be applied rapidly to sort out apparently well person who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic" (commission on chronic illness; italics added for emphasis). The whole process of screening appears to be quite simple but there are several underlying complexities, alike the subject of clinical epidemiology. There are concerns regarding the cost of screening which may be apparent or hidden. Cost can be related to screening process/instrument or treatment of additional cases however, identification of these subjects in the pre-clinical stage by astute screening instrument does make the early intervention possible. Thus screening can facilitate primary and secondary prevention.
Suitable disease & screening:
A variation among natural history of the diseases has an impact on the utility of early detection and treatment. A disease with long pre-clinical phase, like carcinoma of cervix, will definitely require early detection and screening, in order to modify its course. Besides the long latency period, severity of the illness also merits consideration while designing a screening program. A screening program for detection of upper respiratory tract infection will be less cost effective than screening program for breast cancer, solely based on the disease morbidity and mortality. In order to have effective screening program the disease under consideration should be an important health problem. The disease should be progressive with serious health consequences. An effective treatment at an earlier stage should be able to modify the natural history and course of illness17.
Major depressive disorder does full fill all these criteria. It is prevalent in community and primary health care setting, if undetected leads to progressive worsening with tragic loss of life by suicide. Long term vulnerability factors like loss of parent/s during child hood by death or separation and current non confiding spousal relations does lead to sub threshold symptoms. Thus detection of this preclinical phase of illness by screening test helps in early intervention and subsequent modification in its natural history.
Suitable test & instruments
There are certain consideration regarding the choice of screening test and instrument. Screening test should be inexpensive, easy to administer with minimal discomfort to the clients. Colonoscopy might be very effective in early detection of carcinoma of colon, but it has limited acceptability in routine use for apparently healthy subjects. Another important characteristic of good screening instrument is its ability to separate people with and without disease. A robust screening instrument should have high validity and reliability.
Validity & Reliability (Precision)
Simply stated, a test is said to be valid when it does what it is suppose to do. This is usually measured through its sensitivity and specificity. Sensitivity can be described as the ability of the test to identify correctly those who have the disease. In conditional probability notation, sensitivity is written P (T+/D+). Specificity of the test is its ability to identify correctly those who do not have the disease. In conditional probability notation, specificity is written P (T-/D-). Sensitivity and specificity determined by comparing the result with a definitive diagnosis. It is important to note that sensitivity and specificity are reciprocal in nature18.
Consistency and reproducibility of the test is said to be its reliability. It depends upon variation inherent in the method. The variation can be inter-observer or intraobserver. A same individual can rate the same observation differently on different occasions. Alternatively there can be a natural variation among two raters. In rounding off some raters have preference for higher values while others for lower values.
Determining performance of screening instrument (AKUADS) and assigning probabilities:
While the specificity and sensitivity remain an important issue in considering the use of instrument for diagnostic and screening purposes, the psychometric measurement becomes an additional issue when an instrument is applied in a cultural setting which is different from the one in which it was originally developed. EMIC-instruments and questionnaires with cultural sensitive explanatory models are reported to be preferable over ETICinstruments (instruments developed in another cultural setting). But research findings of studies using EMICinstruments only, without established cross cultural validity are open to question.
Aga Khan University Hospital Anxiety & Depression Scale (AKUADS) is a 25 item screening instrument, developed indigenously in the primary health care and psychiatric setting of Pakistan, for screening depression and anxiety disorder. It incorporates culturally pertinent somatic metaphors of depressive disorder. It has an advantage over ETIC instruments, in assessing locally relevant idioms of distress in the primary health care settings in Pakistan. To assess the performance of a screening instrument i.e., AKUADS, we take a hypothetical population of 10000 and calculate the sensitivity, specificity based on the sensitivity and specificity found in the literature.
Sensitivity & Specificity of Aga Khan University Anxiety and depression scale (AKUADS) as a screening instrument*
Summary of test performance characteristics (as stated in the published reports)4
These test characteristics can be used to generate 2 x 2 tables, or decision matrix, using an arbitrary sample size of 10000 patients (table 1). This can be used to assign probabilities to the branch node C-2, thus an accurate estimate of how the screening instrument is functioning.
Bayes' rule is a mathematical formula that can also be used to calculate unknown conditional probability, such as predictive value positive [P (D+ /T+)] directly from the reported values for sensitivity [P (T+/D+) = 0.66], specificity [P (T-/D-) =0.79] and prior probability of major depressive disorder [prevalence, P (D+) = 0.30]19. Thus,
In above example 1-sensitivity will be interpreted as probability of test results as negative given the disease status to be positive. For any screening instrument false negative rate is a major concern. This is particularly so in the context of primary health care in Pakistan. FNR of 0.34 means that quarter of a patients attending primary health care will be misclassified, therefore, losing valuable opportunity of early recognition and intervention.
In this circumstances use of another screening instrument simultaneously or sequentially can serve to rectify this potential problem. Use of two screening instruments simultaneously will serve to increase the sensitivity while sequential use will increase specificity. The choice for either mode of screening depends upon the purpose of screening.
With a population to psychiatrist ratio of 1: 100,000, primary care in Pakistan serves as the sole care provider, unlike its filtering role in western countries20. Therefore high specificity is desirable in the contest of Pakistan. Thus sequential screening using AKUADS followed by another instrument/tool might be more desirable. Diagnostic confirmation based on DSM-IV diagnostic criteria described by Reza H et al can be used sequentially with AKUADS, in the context of primary health setting in Pakistan21.
Depression sub-typing: differences in primary care and psychiatry (Node D-2):
There are number of factors mentioned in literature regarding "type" of depressive disorder seen in primary care and psychiatry. Patients seen in the two settings may be quite different. Depression seen in primary care is less severe and less impairing. Evidence of this comes from Michigan Depression Project (MDP), a longterm study of depression in primary care that has provided valuable data regarding the similarities and differences between depressed patients in primary care and psychiatry and whether the same treatment is appropriate in both settings.
In its first phase, MDP screened 1928 adult patients from fifty family physicians practices in southeast Michigan and completed structured diagnostic interviews on 425 distressed primary care patients and 123 depressed psychiatric outpatients using the structured clinical interview for DSM-III-R (SCID). Clinicians were asked independently whether each of the patients was clinically depressed. The full sample received comprehensive assessment of stress, social support, overall health, health care utilization, and depression severity at intake and 4.5and 9 months after enrollment. Of the 425 depressed primary care patients, 13.5% were diagnosed with Major Depression, but over 40 % of those meeting the criteria for MDD were mildly depressed. Many of the primary care patients with mild or moderate depression were not diagnosed; family physician only diagnosed 35% with MDD and 28% patients with any depressive disorder22. However detection rate for severe depressive patients was significantly higher; 73% of severely depressed patients were selected compared with 18.4% of mildly depressed patients.
In case of functional depressive disorder severity of the illness has implication on detection rate (D-2). Detection rate for sever depressive disorder is 73 % while detection rates for mild-to-moderate depression is 18.4%. This is in the context when 80-to-86% of the Depressive disorders is mild-to-moderate in intensity. In primary health care mild-to-moderate depression is the most common presentation as compared to psychiatric setting23. The severity of illness has implications for treatment; as mild to moderate depression is best treated by psychotherapy. Sever depressive disorder will invariably require anti-depressants medication therapy. There are no studies on severity of illness and its subsequent detection rates in primary care setting from Pakistan. This is shown in chance node C-5 and C-6.
Treatment option in primary care (Node D-3):
The third decision (D-3) is related to the available choice of therapies. General Physicians can prescribe short term (8-10 sessions) psychotherapy. Mild-to-Moderate depression is preferably treated with short term psychotherapy/counseling, in the setting of primary health care. However, the option of psychotherapy needs to be discussed with the patient, with clear delineation of utility and outcome.
In a randomized control trial, Ali et al showed the effectiveness of psychotherapy when conducted by minimally trained therapist. Short term counseling was particularly effective in low income group and can be usefully delivered in primary health care setting24.
Chance nodes on remissions and relapses are given in the decision making tree. Unfortunately there is no literature on the long term outcome of specific treatments for depression from Pakistan. In cases of relapse of the illness it is advisable for the Primary care physician (health worker) to refer the patient to a psychiatrist.
Decision node D-4 pertains to choice of psychotropic medication in cases of depressive disorder with moderate to sever intensity. There are no studies on the long term outcomes of depression in the context of Pakistan. Extrapolating findings from western literature, around 60 % patients with depressive disorder relapse with in a year. This is in the situation of successful response to psychotropic medications. However in the context of primary care setting in Pakistan, any recurrent and relapsing case should be referred to a psychiatrist. There may be complicating psychosocial determinants or co morbid psychiatric problems (personality disorders), that may be safely treatment by mental health physician.
There are certain limitations to this decision analysis. The data on outcomes and utilities is based on western literature; its generalizibility to the culturally unique setting of Pakistan needs to be considered carefully. Prospective data from primary care settings is required, in order to develop any robust model that serves decision making for management of depression in the context of primary care in Pakistan.
The author wishes to acknowledge Dr. Esfandiar Maram, for his inspirational teaching of Epidemiology & Biostatics. His keen interest in psychiatric epidemiology led to initiation of this work.
Assuming 30 % prevalence rate of MDD in primary health care, in a hypothetical population size of 10,000 people, screened with AKUADS, with a sensitivity of 66% AKUHADS will correctly identify 2,070 individuals who has the disease. It will however fail to detect 930 individuals who have depressive disorder. Similarly with a specificity of 79 % it will detect their disease free status among 5,530 individuals out of 7,000. However it will misclassify 1470 disease free individuals as disease positive, thereby creating some, albeit transient anxiety among them.
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Home » Apprentice Storyteller » Ropes of Lightning
Ropes of Lightning
By Apprentice August 18, 2018 September 14, 2018 Apprentice Storyteller, Idea Pile, Story
NOTE: This post is inspired by This Reddit Post and as such, the idea is entirely credited to u/LeastCoordinatedJedi and his kid.
Captain's Log of the Vessel Wayward Cloud. Date unknown.
Note about time and date: Date is unknown due to total lack of celestial objects. I do not know if the stars or sun and moon are even present, as candles don't even shed light here – they are only a dim point in the shape of a flame – though the air itself seems to be giving off some unnatural light. It confuses me when I try to think about it, and gives me a headache. It has probably been about 3 weeks since our vessel was lifted off the waves.
Note about our ship: I would call our ship a Galleon, so we thought ourselves quite safe in these waters (what with a full compliment of crew to fight pirates or monsters). but we lost a mast, multiple spars, and many sails, so we are rigged almost like a schooner at this point. I do believe now that we will not be returning to port for repairs.
Enough about the ship. It's no longer in the waves. This story is being entered in the ships logs and my personal diary in hopes that my logs will find their way back to civilized lands where monsters do not roam about uncontested. I hope that either a college of sorcery will be made aware that one of their member are attacking ships off the coast, or that the powers of the empire will be alerted and focused on those that have so treacherously preyed upon ships in the region.
We begin with the child that we found on flotsam – the partial wreckage of at least 2 ships. He had quite the story to tell, and I didn't believe him, until I saw it for myself.
We found young J-dai (he insisted with the enthusiasm that only 5-year olds can generate that his name was spelled exactly this way) clinging to flotsam of a merchant ship that was obviously attacked by pirates. Pretty ballsy of the pirates – this was an important shipping corridor, so the imperial patrol and even privateers like us were often found in these waters, and no-one takes kindly to black flags. We found him among the wreckage of 2 other ships, and he claimed that a third had been lifted to the sky. At first, we thought that J-dai was only mistaken as not nearly enough wreckage was available to be from 3 different ships, but then we found separate main masts still connected to badly bent straps and bolts that could only have been ripped apart from below the deck of 3 different ships.
The crew felt that we should have left with haste, but I disregarded their protests as silly superstition and thought that staying would be a good way to increase the reputation of professional privateers on these waters. I decided to look for further survivors to return to their loved ones and perhaps cargo that I might return to their rightful companies (and of course, claim for myself if no company brand was found). To my great shame, I led my poor crew and my beloved ship to cursed clouds of demon light and no lands, and I fell in to this trap while selfishly trying to improve the lot of privateer captains. If only we could have sunken under the waves with the first blast.
We found scattered foodstuffs and a few bales of cotton (details in the clerks log). All the other cargo seems to have been sunk or taken by the attackers. We found no other survivors, and we found no dead bodies. It was almost as if someone had scoured the sea for men, living and dead, and plucked them up with no regard for the other valuables in the salt. This was odd, as almost anyone attacking a ship will take whatever food they can find to bolster their own stores, and we found many barrels of brandy, apples, wheat, and other food.
The boy told me a quick version of his story while recovering with some hot food and a little wine in the captain's cabin, and told a long version of his story later to some sympathetic sailors before we were attacked. I was not present for the long version, but here is my best recollection of his short version:
First off, I can tell is that he has no idea why they were on a ship. I did my best not to allow him to think that I thought his story was preposterous – young minds are very imaginative, but they often have the seed of truth to their stories. I realized quickly that I would not know where he embellished his imagination, but it turns out to be far less than I initially thought.
In his abbreviated version, he tells me that his father was a merchant company's ship captain and there being 2 other ships with him was quite notable – the little boy was very proud of his father for the promotion (his story kept changing the particular rank – captain, admiral, mate, etc.). It seems they had outrun a storm for nearly 2 days in the straights at the nearby islands and the crew was totally exhausted, so they dropped anchor to let the entire crew rest and eat well for a morning.
J-Dai says that when the sailors were getting ready to be under way, the cries went up that the storm had caught up to them again and the whole crew began desperately trying to get farther away from the rocky shore – the boy was very insistent that earlier there had been an argument between senior staff that they were too close to some rocks and "150 paces is too close after that storm" – and there was great confusion about which way to go. The boy said that a great wind came up as a dark cloud overtook them, and "a huge red frog fell out of the sky – a frog sailor with black pants, standing on two legs." When the frog-sailor fell on his ship, it cracked the planks near the main mast. He watched as this invader then tied "a piece of lightning" to the mast, which was suddenly met by the sky as well – with a "big giant noise" – lightning came down from the newly formed clouds to join the piece tied to the mast, and while he was watching this from the captain's cabin, he heard more noises and saw the other ships suffer a similar fate.
After this, his story gets even more confused, as the melee was joined in full – with apparently more monsters coming down the lightning to join the red frog sailor. He doesn't know when the masts were torn from their bolts, but his father threw him on a mast as it fell over, apparently to simply get his child off the doomed ship. The boy hid, terrified, under the sail on a spar and he heard a lot of things happening in the water, and then the sound like a waterfall – he peeked out at that point and saw the noise was from water falling off the hull of the last remaining ship being lifted by "ropes of lightning twisted into a braid" into a "great purple hole in the clouds" – and he saw a stone castle through the hole as well, swearing that a witch was watching the whole encounter while standing on the water. The witch apparently walked up in to the cloud as it was disappearing. He waited more than a day on the now-calm seas before we showed up.
Once his story was over, I let the senior crew know that we may have a pirate on our hands, and they may have a renegade sorcerer with them. I feel that I took warnings from young J-dai's story, but while correct, they were insufficient. Looking back, I was very prideful in thinking that our ship was impervious to a sorcerer-pirate. Even with a battle-tested crew, I should have taken the warning an weighed anchor immediately.
The boy ate voraciously – I did not doubt the time frames that he told us. After a few more hours of scouring the wreckage for salvage (it helped that the sea was very calm – more like a fishing-pond) I began to get uneasy after finding the third ship's mast – an experienced sailor could tell in only a few moments how many ships the discarded sails were from.
And then it happened. A shadow came over the waters, further out to sea than ourselves. Cast by a great purple cloud, it was boiling and moving and glowing with an energy that is foreign to my eyes. This witch-cloud was growing and moving quickly from the sea towards shore, but it never got to the shore – it found my ship and stayed over it, blocking the sun from our search – making it almost like twilight, it was so wide. Cast by a great roiling purple cloud, I began to give the boy's story more credence – this must be the work of some powerful magic-user, as it could not be a typical storm. I immediately gave the order go regather the men from the boats in the water – we either needed them for the fight, or we needed the boats to flee upon.
As the first men got up from the sea to the main deck, I heard a sound that was loud like a clap of nearby cannon fire, but distant and rolling like thunder. The men were armed with saber, hook, and crossbow, and to their credit not a single one turned to give me shame for staying in those haunted waters – they each took up their battle positions and got the last of the men from the boats. We all stood ready, weapons in hand, for a few very long minutes.
Almost I ordered the anchor weighed or perhaps even the ship abandoned – but before the orders were given, the sound of some kind of foreign drum rolled over us. At the same moment, and the whole crew and I were enraptured as we saw a hole begin to open – a great circle whose edge was naught but roiling storm cloud and small splinters of lightning. The noise happened again and again, and I realized that the portal was opening ever-wider with each strike of the distant drumhead. And as we watched the spectacle, the true horror of what we were seeing came upon us. In the distance through that portal, we saw a great palace upon a hill of rock and boulders.
There was something not right about the way that we were looking at it. Almost like we were above it, but also like the front gates, all the pillars around the outside, and the roof were connected by a single acute angle instead of many obtuse ones. Perhaps it is best to describe it like we were within a trick mirror that was pointed at the fortress? Bah! I consider myself a man of letters but cannot fathom the words that should successfully describe how the hill and fortress were oriented to us.
The building glowed with sickly inner light and my mate held a spyglass and yelled that there were great crystals on all the ramparts, attended by some kind of monster, and that the sounds were made by these crystals.
As he watched, he reported with shock that creatures were climbing these magical devices by the dozen, and these stood waiting, looking to our ship, and then with a terrified scream he said that they were being launched off of the crystals toward us. I told the mate to keep his gaze upon the first ones that went in this way, and tell us when they would land on us. In a quick whisper he related "Only a few moments! At least a dozen in the first volley!" was his report, and then dropping the spyglass he roared "BLADES READY!"
Just as he said this, there were the sounds that no sailor ever wants to hear – the cracking and splintering of the planks of the deck. As the splinters settled, we were able to see it clearly – a monster that was in the general shape of a giant man – all the sailors were too stunned to rush initially, so it stood up from it's landing crouch while we took in what we were seeing.
It's stance was like that of a great bear on two legs, but even less clear delineation between the skull and the muscles of the broad back, and no fur. It stood taller than any man I have ever seen – with sloped shoulders and great long arms. It stood on two legs and wore black pants. It's head was low to it's shoulders and wide, with eyes more on top than in front, and a great mouth that almost seemed to reach to the back to it's shoulders. It was colored a deep crimson, mottled with large brick-red spots on it's head and back. It was indeed exactly the beast from J-dai's story – somewhat frog-shaped in the face and wearing black pants. The invader was even holding a short length of chain that glowed bright like a blue sun. As we watched, it held one end of the chain in it's fist up to the mast; the way you might knock on a door while holding a tool in the same hand.
As he did this, the rest of the monsters were landing, also cracking boards with the force of impact. The noise shook us out of our astonishment and some men charged. The frog-men (who were made in various colors) had already rushed to defensive postures around this one, apparently so that he could finish his work.
I stayed back for a moment longer, in order to perhaps find an opportunity to get past the monster's companions and engage with it more fully. The chain which initially appeared very short suddenly wrapped itself around the mast and the crimson beast let go, just as a great bolt of lightning streaked out of the sky with a huge thunder clap and joined the chain. All the men disengaged and took a few steps back. Unlike lightning, this thing maintained its presence – as soon as it hit it fell slack like a great rope made of vibrant blue-white light.
As I stood back, the other sailors and I realized that we were bested physically – the monsters didn't seem interested in a fight and kept simply catching our arms as we swung blades and maces, and pushing us back as their companions continued their work with the chains and lightning – some of the other monsters that landed also had the glowing chains. We got a few good hits, but none that were mortal.
It was in that moment of tense, industrious calm that I realized the true horror of what was happening. The ropes of lightning were losing their slack – whatever great wheel that had these devices mounted to it is turning and tightening the ropes. We were being lifted to that infernal castle. The weight was being put on the masts and anything that looked like it could bear the load. There were at least a dozen points the ropes of lightning were connected.
Some of the points began to buckle – some were attached to rails, to spars, and some just to planks. The first of these to buckle shocked us out of our horror and I cried "Kill the invaders! Your life is in your hands!" and to my great pride, every single sailor rushed as one and we slew several of the frog-men in the initial rush. The invaders then began to take us seriously and truly fought back.
The larger invaders would cleave off a limb with a single swipe of their falchions, but we could not kill them without the concerted effort of a dozen of us. We could overwhelm a few more, but they only fought us until we could feel the ship -the entire ship- lifted from the water. We all felt it begin to spin, and the invaders immediately ran to the points where the ropes of lightning were attached, and they began to scramble up the blue lines. We got a few more of them, but our doom was sealed.
One by one, my sailors – my friends – turned from the spectacle above us to look to me for direction. When I realized they expected an order, I gave it. "Abandon ship. She's been captured, but we need not be captured as well." Several men went to the life-boats, but then one man just dove off the side. He fell up into the purple hole in the clouds. His confused yell turning to terrified screaming will haunt the rest of my short days. We watched him float up through the purple air, and fell past the hill that the palace is on, and then we heard it – a great cackling.
There was laughter coming from the sea.
There was a woman. A woman standing on the sea, apparently still casting a spell in a circle of torches that floated about her.
She was in thick, black robes. Her auburn hair was flat around her shoulders – no wind seemed to touch her. She was standing in a circle of torches that were arranged on the water below us. I do not know what magic she used to stand there, but considering the sight above us, it did not seem unfeasible. She did not seem young or beautiful, but she also did not seem old or ugly. But as we caught sight of her, we felt the power of her.
As we breached the purple cloud, she seemed to be finished, and ascended past us by walking on the air. A few of my men fired crossbows at her, and one even hit. She did not seem to notice that a bolt was pinning her robe to her ribs. We lost all spirit of violence at that.
We suffered from extreme horror then. We were being pulled from our native waters to be prisoners in a world where frogs command high magic and even geometry did not seem to make sense. We thought initially that we would be pulled to the rocks and dashed before the palace. But his was not so. We were merely tethered. The men waited in silent anticipation for hours.
And the terror passed.
Terror turned to boredom.
Initially, I kept the crew busy doing normal maintenance of the ship, and rigging her up as if we expected to be plopped back in the water any minute. There are a dozen or so other ships that we have been able to signal with flags and with oil lamps, but we cannot get close enough for real exchange of information. The crew is doing their best to stay entertained, but music doesn't seem to sound right, and both dice and cards seem silly when you will likely never see the use of money again.
So now we are waiting for the end. Some of my crewmates have hastened that for themselves – jumping off always seems to have them fall forever past the palace and the rocks. We do not know if they ever find a sea or land. Others tried to climb the ropes of lightning – but it feels to the touch like a greased pole of hot brass. The only distance you can go is determined by your initial jump, and you can't hold on for long, anyways.
We are beginning to come to the end of our food stores.
Some crew have suggested a feast of the last of the rations, since there is no hope of rescue. Force the sea witch to deal with us or let us die.
In the end, I do think something will happen. As I write this, I see that one of our fellow tethered ships is throwing all it's cargo over the side, and I can see the palace responding – the frog-men are launching again to them. Whether to deal with them properly as prisoners and feed them, or simply to slaughter them for wasting wealth I do not know, but it would certainly be better than this incessant waiting in the purple air.
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Getting back to it. »


Abdominal Distension and Digestive Disorders
More in Irritable Bowel Syndrome
Causes & Diagnosis
Support & Coping
Barbara Bolen, PhD
Barbara Bolen, PhD, is a licensed clinical psychologist and health coach. She has written multiple books focused on living with irritable bowel syndrome.
Medically reviewed by Emmy Ludwig, MD on August 05, 2016
Emmy Ludwig, MD, is board-certified in gastroenterology and hepatology. She practices at the Memorial Sloan-Kettering Cancer Center in New York.
Emmy Ludwig, MD
Peter Hince / Getty Images
Distension is defined as something that is enlarged or stretched beyond its normal state, typically from within. Abdominal distension is a sense of increased abdominal pressure that involves an actual measurable change in the circumference of a person's abdomen.
Distension can be measured through the use of a tape measure. Distension over the course of a day can be measured more reliably by a device known as ambulatory abdominal inductance plethysmography (AIP). Such a device would most likely only be used during the course of a research study.
How Is Distension Different than Bloating?
When a person feels bloated, they experience a sense of increased pressure in their abdomen, but without any measurable change. With distension, there is an actual widening to the size and circumference of the abdomen. Many people, including doctors, will often use the two terms interchangeably.
Although the causes of both bloating and distension have not yet been well-identified, there are some research indications that different (but related) mechanisms may be underlying each of the two problems.
Bloating and distension are symptoms that are most characteristic of a functional gastrointestinal disorder (FGD), such as irritable bowel syndrome (IBS).
How many people who have IBS experience distension alongside bloating? Estimates range from 50 to 75%. These patients are more likely to report it as a highly bothersome symptom. Distension is more likely to be reported by patients who have constipation-predominant irritable bowel syndrome (IBS-C) as opposed to diarrhea-predominant IBS (IBS-D). Studies have shown that a slowing of the transit time of fecal matter through the gut is related to the experience of distension.
Typically, patients will report that distension is more likely to occur after meals and will worsen as the day goes on, with a reduction in the symptom overnight.
Distension that increases as the day wears on is most likely due to an FGD. Distension that occurs 24/7 may be indicative of a more serious health problem.
Although it seems like common sense to say that distension is related to excessive amounts of intestinal gas, this theory has not been fully supported by research. Rather, it may be that it is the way that the digestive systems of people who have IBS handle the gas that is the problem.
Another theory suggests that distension is related to a dysfunctional reflex of the muscles of the abdomen, triggered by the act of eating a meal. More research is needed to validate or discount this theory.
There are a variety of things that can cause abdominal distension (as well as bloating). Therefore there are no treatments identified that specifically target the symptom of distension. Instead, treatment focus on dealing with the symptoms of the overall digestive disorder.
One of the most challenging aspects of having IBS is trying to figure out what's safe to eat. Our recipe guide makes it easier. Sign up and get yours now!
Agrawal, A. & Whorwell, P. "Review Article: Abdominal Bloating and Distension in Functional Gastrointestinal Disorders -- Epidemiology and Exploration of Possible Mechanisms" Alimentary Pharmacology & Therapeutics 2008 27:2-10.
Lea, R. & Whorwell, P. "Expert Commentary – Bloating, Distension, and the Irritable Bowel Syndrome" MedGenMed 2005 7:18.
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Jack Allen's Kitchen 360 Is Now Open For Lunch, Dinner, And Brunch
It's Jack Gilmore's third restaurant.
by Nadia Chaudhury Apr 15, 2015, 12:30pm CDT
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Jack Allen's Kitchen 360
The Westlake location of Jack Allen's Kitchen is now officially open for lunch, dinner, and Sunday brunch on Loop 360. The third restaurant is helmed by chef Jack Gilmore. The farm-focused kitchen will serve the same sort of Texan comfort food fare, with some additional new items to the menu and cocktail list. It's also the home of Jack Allen's first wood burning oven. Dinner tonight features fried quail legs, stewed red chile pork shoulder, and a strawberry rhubarb cobbler.
The space, designed by Mann & Mann Architects, includes canning jar chandeliers, plenty of reclaimed wood, and other vintage details. Outside, there is a patio with both a fireplace and television screen. 360 is open from Sunday through Thursday from 11 a.m.-10 p.m., Friday and Saturday from 11 a.m.-11 p.m.. Sunday brunch is served from 10 a.m.-2 p.m.
The new restaurant took over the former Trento space last spring. The restaurant opened for dinner service only last week.
Jack Allen's Kitchen [360]
3600 N Capital of Texas Hwy Ste D, Austin, TX 78746
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